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Essay Available:
Pages:
4 pages/≈1100 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
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Date:
Total cost:
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Topic:

Commercial Insurance Reimbursement and Capitation

Coursework Instructions:

Assignment: Commercial Insurance Reimbursement and Capitation

You have been hired as the billing manager for Nash Medical Center and Clinics. One of your responsibilities is to calculate what the patient owes and what the insurance company owes, so that you can determine what revenue to expect for these services. You have the charge and the usual, customary, and reasonable (UCR) amount. The reimbursement will be calculated on the 80/20 distribution. The deductibles for each of these patients have been met. Under this insurance plan, $20.00 copays are due for primary care physician office visits and $40.00 copays for specialists. There is no copay for other services.

The Medical Center also recently negotiated with a group of employers to treat their patients based on a capitated amount of $750 per person per month (pmpm) This group of employers has combined 6,525 employees. You predict that your cost will be $610 per month per person.

The budgeted revenue was initially $1,575,000.

Coursework Sample Content Preview:


Commercial Insurance and Capitation
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Due Date
Part 1: Patient’s Responsibility for Completing the Chart
Service

Charge

UCR

Patient's Copay

Patient's Coinsurance

Insurance Pays

Patient Owe

Internal medicine

$120.00

$120.00

 $20

 $24

 $96

 $44

Physical therapy

$150.00

$97.00

$0

$19.40

$77.60

$19.40

X-ray

$115.00

$73.00

$0

$14.60

$58.40

$14.60

MRI

$1,845.00

$147.00

 $0

$29.40

$117.60

$29.40

Specialty visit

$165.00

$90.00

 $40

$18.00

$72.00

$58.00

Specialty visit

$75.00

$70.00

 $40

$14.00

$56.00

$54.00

Lab test

$32.00

$19.00

 $0

$3.80

$15.20

$3.80

Lab test

$45.00

$29.00

 $0

$5.80

$23.20

$5.80

Mammogram

$151.00

$95.00

 $0

$19.00

$76.00

$19.00

The reimbursement, patient’s copay, patient’s coinsurance, and what the patient owes was calculated based on the 80/20 distribution threshold, particularly with respect to the provided UCR and charges. Patient copays are a standard cost-sharing approach under different health insurance programs. Cost sharing can be conceptualized as the portion of costs the patient covers out of pocket. Coninsurance implies the patient’s share of costs that are covered by healthcare service, computed as a percentage of the authenticated amount for the service (Centers for Medicare & Medicaid Services, n.d.). The patient is expected to pay the coninsurance as well as any deductibles that they owe. The patient’s copay was internal ...

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